Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally

Key Points Question What is the association between antimicrobial stewardship programs (ASPs) implemented across multiple health care settings and antibiotic use? Findings In this systematic review and meta-analysis of 52 studies with more than 1.7 million patients conducted in different health care and income settings, ASPs were associated with reduced consumption of antibiotics overall as well as of antibiotics in the World Health Organization Watch group. Meaning The findings of this study support the use of ASPs to reduce antibiotic use in both hospital and nonhospital settings.

In each component, a rating of strong, moderate, weak has to be assigned according to rating guidelines and dictionaries. For global rating of each paper, "Strong" rating was given when there are no weak ratings in all components, "Moderate" for one weak rating and "Weak" for two or weak ratings in one of assessment. Only articles with "Strong" and "Moderate" ratings were included in our analysis. We only included articles with high study quality that had strong or moderate ratings in at least 5 out of the 6 domains.  Educating prescribers, pharmacists, and nurses about adverse reactions from antibiotics, antibiotic resistance, and optimal prescribing e.g. interactive workshop and educational seminar  Developing or updating guideline and protocol about appropriate antibiotic use e.g. develop community-acquired pneumonia guidelines for hospitalists. Decision support tools  Decision support through electronic or paper-based strategies for antibiotic use e.g. electronic-based treatment algorithm or a poster with a clinical algorithm Antibiotic restriction  Restricting antibiotic use by interventions, such as preauthorization, requires prescribers to gain approval before using certain antibiotics. e.g. preauthorization through an electronic order entry system or ID physician. Prospective audit and feedback

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An external review of antibiotic therapy by antibiotic experts (usually physicians and/or pharmacists), e.g. case-by-case review of patients prescribed antibiotics by an infectious diseases (ID) physician. Tracking  Monitoring and evaluation of antibiotic prescribing and other vital outcomes (antibiotic prescribing and outcome tracking systems) and reporting prescription practices, infection and resistance patterns, e.g. monitoring C. difficile infection and resistance patterns.

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The engagement of pharmacists in ASPs to improve antibiotic use. The pharmacist's role in ASPs is to document antibiotic indications, dosage adjustment, and duplicative antibiotic therapy alerts and to monitor antibiotic-related drug interactions and adverse effects e.g. clinical pharmacist provides a notification to switch antibiotic therapy.

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Antimicrobial susceptibility testing results to show antibiotics that are in line with hospital/clinical treatment guidelines or ASPs and to help providers in clinical decision making with microbiology report e.g. antibiotic culture and sensitivity test report. Figure 1 shows the average change in antibiotic consumption post-compared to pre-intervention. RR:rate ratio. The rate ratio (RR) of antibiotic consumption was obtained by dividing the post-intervention consumption rate measured in DDD or DOT per 100 PD by the pre-intervention consumption rate. A rate ratio below the value of 1 indicates that ASPs are associated with a reduction of (1-RR)% in antibiotic consumption. Numbers quoted in percentage terms are the weights assigned to each effect size by the three-level random effects model. 95% confidence intervals are included in brackets. No significant reduction in consumption was measured among studies that reported consumption pooled across antibiotics (RR=0.82, 95% CI [0.66 to 1.02]; 5 estimates).
© 2023 Zay Ya K et al. JAMA Network Open.

eFigure 2. Subgroup Analyses (Antibiotic Prescriptions)
A Forest plot of included studies stratified by patient settings (Antibiotic prescriptions) Figure 2a shows the stratified results for the average change in the proportion of patients receiving an antibiotic prescription in the post-intervention compared to the pre-intervention period. This was calculated as the proportion of all patients that received an antibiotic prescription post-intervention minus the same proportion measured in the pre-intervention period. For randomised controlled trials, pre-intervention differences in the proportion of prescriptions between treatment and control groups were subtracted from post-intervention differences. A negative effect size indicates that ASPs are associated with a reduction in antibiotic prescriptions of magnitude equal to the value of the effect size itself. Numbers quoted in percentage terms are the weights assigned to each effect size by the three-level random effects model. 95% confidence intervals are included in brackets.  Figure 2d shows the stratified results for the average change in the proportion of patients receiving an antibiotic prescription in the post-intervention compared to the pre-intervention period. This was calculated as the proportion of all patients that received an antibiotic prescription post-intervention minus the same proportion measured in the pre-intervention period. For randomised controlled trials, pre-intervention differences in the proportion of prescriptions between treatment and control groups were subtracted from post-intervention differences. A negative effect size indicates that ASPs are associated with a reduction in antibiotic prescriptions of magnitude equal to the value of the effect size itself. Numbers quoted in percentage terms are the weights assigned to each effect size by the three-level random effects model. 95% confidence intervals are included in brackets.(Antimicrobial Stewardship program= multi-component ASPs) Figure 3a shows the stratified results for the average change in antibiotic consumption post-compared to preintervention. RR:rate ratio. The rate ratio (RR) of antibiotic consumption was obtained by dividing the postintervention consumption rate measured in DDD per 100 PD by the pre-intervention consumption rate. A rate ratio below the value of 1 indicates that ASPs are associated with a reduction of (1-RR) % in antibiotic consumption.
Numbers quoted in percentage terms are the weights assigned to each effect size by the three-level random effects B. Forest plot of included studies stratified by antibiotic restriction as per individual protocol settings (Antibiotic consumption in DDD per 100 patient days) Figure 3b shows the stratified results for the average change in antibiotic consumption post-compared to preintervention. RR:rate ratio. The rate ratio (RR) of antibiotic consumption was obtained by dividing the postintervention consumption rate measured in DDD per 100 PD by the pre-intervention consumption rate. A rate ratio below the value of 1 indicates that ASPs are associated with a reduction of (1-RR) % in antibiotic consumption.
Numbers quoted in percentage terms are the weights assigned to each effect size by the three-level random effects